Clinical Picture
Allergic contact dermatitis and tracheobronchitis associated
with repeated exposure to tear gas
Rex Pui Kin Lam, Kin Wa Wong, Chi Kin Wan
A 27-year-old man came to our emergency department
with shortness of breath, a cough, and a globus
sensation, which had all started earlier in the day. He
also complained of an itchy rash on his neck, chest, and
arms, which had developed 2 weeks earlier. During the
previous 6 weeks, he had been repeatedly exposed to tear
gas while working as a photojournalist at different
protests around Hong Kong; the last exposure was
11 days before he came to see us. He said he had worn a
full-face respirator during recent episodes.
The patient had attended our department on
three previous occasions because of the rash. He had
been given oral prednisolone, antihistamines, and topical
steroids but his symptoms had not improved. He had a
history of allergic rhinitis; he had no history of asthma or
bronchitis.
On examination we found the patient to have a
blanchable, maculopapular rash over his neck, upper
trunk, and arms—consistent with an allergic contact
dermatitis (figure). His respiratory rate was 18 breaths
per min and his oxygen saturation was 100% on room
air; there was no evidence of angio-oedema involving the
upper airway. His lung fields were clear on auscultation.
Blood investigations showed no abnormalities: the
patient’s absolute eosinophil count and serum IgE
concentration were normal.
A chest x-ray and thoracic CT showed no abnormalities.
Bronchoscopy showed mild pharyngitis but severe
tracheobronchitis (figure; video). No pathogens were
detected with PCR or culture of the bronchoalveolar
lavage fluid. We decided not to do a bronchial biopsy of
the severely inflamed bronchi because we were concerned
about the risk of bleeding caused by the procedure.
Lung function tests showed normal spirometry but a
significant bronchodilator response: an increase of 19%,
640 mL in forced expiratory volume in 1 s, and a slightly
reduced oxygen diffusion capacity of 71% (normal
range 75–125%).
Considering the patient’s presentation in the round we
believe the patient had severe tracheobronchitis and an
allergic contact dermatitis due to repeated exposure to
tear gas. The patient was admitted and given intravenous
hydrocortisone, inhaled fluticasone and vilanterol, and
50 mg/day of oral prednisolone. His condition improved
and he went home after 4 days.
At follow-up 6 weeks later, the patient’s shortness of
breath had improved but he still had the cough. We
repeated the bronchoscopy, which showed improvement
in the tracheobronchitis (figure).
Lung function tests showed a significant bronchodilator
response only in small airways: an increase of 18% in
www.thelancet.com Vol 396 August 1, 2020
forced expiratory flow between 25% and 75% of the Lancet 2020; 396: e12
forced vital capacity (appendix). Published Online
We recommended that he continue with the inhaled July 13, 2020
https://doi.org/10.1016/
fluticasone and vilanterol. Notably, the patient’s skin rash
S0140-6736(20)31560-9
recurred following re-exposure to tear gas. He was given
Emergency Medicine Unit,
three more short courses of oral prednisolone. 4 months Li Ka Shing Faculty of Medicine,
later at a follow-up appointment his dermatological and The University of Hong Kong,
respiratory symptoms had resolved. Pokfulam, Hong Kong Special
Administrative Region, China
o-Chlorobenzylidene malononitrile (CS) has become the
(R P K Lam MPH,
most commonly used tear gas agent—often deployed by K W Wong MBChB); Department
producing microparticles 3–10 µm in size with pyrotechnic of Medicine (C K Wan MBChB),
devices like grenades or canisters. CS is a potent agonist of and 24-hour Outpatient and
Emergency Department
the transient receptor potential cation channel A1, which
(R P K Lam, K W Wong),
is expressed in nociceptors in the skin and mucous Gleneagles Hong Kong
membranes; it triggers pain and an acute inflammatory Hospital, Wong Chuk Hang,
reaction. Exposure also causes immediate intense irritation Hong Kong Special
Administrative Region, China
of the eyes, nose, mouth, skin, respiratory tract, and gastro­
intestinal tract in a dose-dependent manner—these effects Correspondence to:
Dr Rex Pui Kin Lam, Emergency
lead the individual to be temporarily incapacitated. Medicine Unit, Li Ka Shing
Repeated exposure has been associated with chronic Faculty of Medicine,
bronchitis and allergic contact dermatitis which—as in The University of Hong Kong,
Pokfulam, 8526014122,
our patient—may occur despite a normal eosinophil
Hong Kong Special
count and serum IgE concentration. Administrative Region, China
Contributors lampkrex@hku.hk
RPKL and KWW cared for and followed up the patient in the emergency See Online for appendix
department. CKW did the bronchoscopy and lung function tests. We all
collected clinical photos from the patient. RPKL wrote the manuscript.
We all revised and approved the final version. Written consent for
publication was obtained from the patient.
See Online for video
© 2020 Elsevier Ltd. All rights reserved.
A B
C
Figure: Allergic dermatitis and chronic bronchitis after repeated exposure to tear gas?
(A) Maculopapular rash over the patient’s neck and chest. (B) Bronchoscopy image shows severe tracheobronchitis.
(C) 6 weeks later repeat bronchoscopy image shows improvement in tracheobronchitis.
e12